In 2016 the family medicine department at the Donald & Barbara Zucker School of Medicine at Hofstra/Northwell (located in NY State) recognized the slow evolution of hospice & palliative medicine (HPM) in the US and it’s place in Family Medicine education and clinical work. Even though HPM is part of the curriculum in graduate medical education, there was still a deficit when it comes to the comfort level and perceived competencies of practicing physicians upon graduation.
We decided to do a gap analysis on HPM education and competency and take steps to implement a year long program to help re-educate our clinicians.
IRB approved surveys were created to be filled out by students, residents and physicians in family medicine across our health system and the New York State Academy of Family Physicians. The survey included some questions addressing the following:
- The importance of ascertaining a patient’s end of life preferences
- Hospice care as a competence for physicians
- Eligibility for hospice
- Barriers to hospice referral
- Comfort level in giving bad news, discussing prognosis, pain management, dyspnea at the end of life, advanced directives and principles of withholding/withdrawing therapy
- Length of time practicing medicine
- Previous palliative/hospice training
Among residents, medical students and attendings, there was a range of exposure to HPM and a general feeling that more training would be beneficial. The data showed a gap in the perceived competency and comfort level of family medicine physicians regardless of their having had HPM education in medical school or residency.
In 2018 we surveyed family physicians at the World Organization of Family Doctors (WONCA) which included respondents from Australia, China, Finland, Korea, Lebanon, Nigeria, Singapore, Taiwan and the US. We compared the results between NY State physicians and the WONCA physicians as regards HPM attitudes and experiences. Using a Lichert scale where 1 represented “not important at all” and 5 represented “essential” we found the following results:
- Hospice care as an important competence for FPs scored 4.72 for global docs compared to 4.41 for NY docs
- The responsibility of the ED physician to determine advance directives scored a 3.5 for global docs compared to 3.16 for NY docs
- The importance of discussing advanced directives with patients in a clinical practice scored 4.72 for global docs and 4.39 for the NY docs
- The perception that hospice referral is “giving up” on the patient – 6% of global docs agreed while 2% of NY docs agreed
- The admission that when encountered by a terminally ill patient they would suggest a hospice referral – 72% global docs said “yes” while 100% of the NY docs said “yes”
What was interesting is that both the global and NY docs stated the same barriers to hospice referral, namely time constraints, lack of reimbursement, lack of familiarity, fear of patient/family reaction amongst others.
The results currently show that the longitudinal curriculum may have helped to enhance knowledge, skills and attitudes. Longitudinal education of HPM competencies is important for family physicians to continue to practice this part of medicine and ensure their patient populations are adequately cared for along the continuum of health.
Educational sessions were then created and implemented longitudinally over the course of one year with about 100 participants. We implemented a longitudinal program amongst various family medicine residency program utilizing didactic sessions, simulation, academic conferences, etc.; and one time education sessions with our state specialty society members and our international specialty society members. Learners were given a pre and posttest to evaluate their qualitative assessment of their knowledge of principles in Hospice and Palliative Medicine (HPM) care as well as their actual knowledge.
The curriculum was centered on the topics raised in the survey.
- Definition of hospice & palliative medicine
- Advance Directives
- Role of physicians in HPM care
- HPM eligibility and role in continuum of health care
- Topics within HPM brief overview
- Giving bad news
- Pain management
- Legal issues
- Principles of withholding/withdrawing therapy
Participants self-reported that they benefitted and increased their understanding following the Hospice and Palliative Medicine 101 Session. We then created a Hospice and Palliative Medicine 201 Session, with a greater emphasis on the clinical aspects of HPM. We have also created an elective and 12 week track for residents across our five residency programs allowing them greater exposure to HPM. The training includes online modules, didactics, IEPs, clinical rotations and exposure to local, national and global HPM meetings. Our plan is to have future surveys to determine maintenance of knowledge, utilization of skills and impact on patient care/access.
What we have learned is that there is room for improvement regarding continuous education for family medicine medical students, residents and practicing physicians on HPM and we hope to inspire others to reach out for resources to help in expanding this medical education need.
Tochi Iroku-Malize MD MPH MBA, LoriAnn Attivissimo MD, Maureen Grissom PhD